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Giving residents less time on duty and more time to sleep was supposed to lead to fewer medical errors. But the latest research shows that’s not the case. What’s going on?

Since 2011, new regulations restricting the number of continuous hours first-year residents spend on call cut the time that trainees spend at the hospital during a typical duty session from 24 hours to 16 hours. Excessively long shifts, studies showed, were leading to fatigue and stress that hampered not just the learning process, but the care these doctors provided to patients.

And there were tragic examples of the high cost of this exhausting schedule. In 1984, 18-year-old Libby Zion, who was admitted to a New York City hospital with a fever and convulsions, was treated by residents who ordered opiates and restraints when she became agitated and uncooperative. Busy overseeing other patients, the residents didn’t evaluate Zion again until hours later, by which time her fever has soared to 107ºF (41.7ºC) and she went into cardiac arrest and died. The case highlighted the enormous pressures on doctors in training and the need for reform in the way residents were taught. In 1987, a New York State commission limited the number of hours that doctors could train in the hospital to 80 each week, which was less than the 100-hour-a-week shifts with 36-hour call times that were the norm at the time. In 2003, the Accreditation Council for Graduate Medical Education followed suit with rules for all programs that mandated that trainees could work no more than 24 consecutive hours.

In 2011, those hours were cut even further, but the latest data, published online in JAMA Internal Medicine, found that interns working under the new rules are reporting more mistakes, not enough sleep and symptoms of depression. In the study that involved 2,300 doctors from more than a dozen national hospitals, the researchers compared a population of interns serving before the 2011 work-hour limit was implemented, with interns working after the new rule, during a three-month period. Those in the former group were on call every fourth night, for a maximum of 30 hours, while the latter group worked no more than 16 hours during any one shift. They gathered self-reported data from on their duty hours, sleep hours, symptoms of depression, well-being and medical errors at three, six, nine and 12 months into their first year of residency.

Although the trainees working under the current work rules spent fewer hours at the hospital, they were not sleeping more on average than residents did prior to the rule change, and their risk of depression remained the same, at 20%, as it was among the doctors working prior to 2011. And the number of medical errors the post-2011 doctors reported was higher than that documented among previous trainees. “In the year before the new duty-hour rules took effect, 19.9% of the interns reported committing an error that harmed a patient, but this percentage went up to 23.3% after the new rules went into effect,” said study author Dr. Srijan Sen, a University of Michigan psychiatrist in a statement. “That’s a 15% to 20% increase in errors — a pretty dramatic uptick, especially when you consider that part of the reason these work-hour rules were put into place was to reduce errors.”

How could fewer hours lead to more errors? For one, interns reported that while they weren’t working as many hours, they were still expected to accomplish the same amount that previous classes had, so they had less time to complete their duties. According to the study authors, this may be leading to work compression, and that can increase the risk of errors or mistakes if residents don’t have as much time to make and recheck patient-care decisions. In addition, the pressure may be even greater for residents in many hospitals where the new restrictions on hours were not accompanied by funding to hire new staff to balance the workload.

“For most programs the significant reduction in work hours has not been accompanied by any increase in funding to off-load the work. As a result, though many programs have made some attempts to account for this lost work in other ways, the end result is that current interns have about 20 less hours each week to complete the same or only slightly less work. If we know that timed tests result in more errors than untimed ones, we should not be surprised that giving interns less time to complete the same amount of work would increase their errors as well,” said study author Dr. Breck Nichols, the program director of the combined internal-medicine and pediatrics residency program at the University of Southern California, in a statement.

Another source of errors came as one intern going off duty handed his cases to another. With fewer work hours, the researchers say the number of handoffs has increased, from an average of three during a single shift to as many as nine. Anytime a doctor passes on care of a patient to another physician, there is a chance for error in communicating potential complications, allergies, or other aspects of the patient’s health; that risk is boosted when the transition occurs several times over.

In 2011, Dr. Zachary F. Meisel, a practicing emergency physician and an assistant professor of emergency medicine at the Perelman School of Medicine at the University of Pennsylvania, and Dr. Jesse M. Pines, the director of the Center for Health Care Quality and an associate professor of emergency medicine at George Washington University, wrote in TIME about how dicey more handoffs could be:

Shorter shifts mean more potentially dangerous handoffs, wherein doctors and nurses transfer the care of their patients to a new shift worker who is not as familiar with the patients’ histories and may be less emotionally invested in their care. Handoffs are notoriously fraught with miscommunication and are known to create opportunity for mistakes.

Their suggestion at the time was to encourage napping on the job to improve current problems in sleepy doctors, citing studies showing sleep improving performance and that instituting naps actually did result in more rest among medical residents. They write:

For those of us who trained under the old never-sleep, always-take-care-of-your-own-patients-at-all-costs, tough-it-out system, restrictions on work hours seem soft. Napping in the middle of a shift? That’s a sign of downright weakness. But this persistent macho attitude is part of the problem. Sleep science and studies of shift workers in nonmedical disciplines have repeatedly shown that tired workers not only make more mistakes, but also often fail to identify their own fatigue. Letting tired doctors and nurses take naps, or even forcing them to, may be a workable solution.

The authors of the current study acknowledge that their findings are preliminary and based on reports of depressive symptoms, sleep and medical errors that were reported by the residents themselves. They acknowledge that it may simply take time for the health care system to adjust to the new rules, since long hours have been so ingrained in medical training. But the results hint at some potential unintended consequences of the more restrictive hours that may need adjusting in the coming years. Fewer hours at the hospital means less time for residents to train and learn the skills they need to care for patients; even the staple of resident training, the daily rounds, in which experienced physicians and residents visit each patient admitted to the hospital under their care to review, have been cut short because of the limited hours that residents have on duty.

Figuring out the right balance between humane work conditions that promote the best learning environment for residents and the highest quality of care for patients may still be a work in progress. More research is needed to pinpoint what’s driving the uptick in medical errors and determining the best strategies for improving resident training to bring these rates down.

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This is the most ridiculous disciussion I've read in a long time. The allegation is obvious. Less training results in less experienced physicians, period. But what do you expect in this new age of "touchy, feely, gender/ethnic-centric, feminized healthcare? This is just another attack on the former proud profession of medicine by the government and Liberal Progressive hacks who are more concerned about the feelings and fragile self-esteem of the wimps that are now being admitted to our medical schools. Perhaps we can emasculate the BUDS/S training of our Navy Seals and regulate them to an 8 hour shift when hunting down terrorists or make sure our Army Rangers get a "snack" delivered to them on a mission. These military professionals go through intense training in order to prepare temselves to make critical, snap decisions when sleep-deprived, hungry and in high stress situations. The same training has been used to great success in American medicine. It's part of the indoctrination. I did it and so did several generations of doctors before me. In my time of medical need, I want the quiet, experienced professional; not the pampered, effete and needy Obamatron MD who will soil themselves when I need them at their best. Leave it alone.

this may be silly but what about the training in specialities. as you trickle down from doctor, nurse practitioner, nurse etc aren't they trained in that particular field. so they can bounce ideas off each other. not to mention -and i guess they would have these- printed reference books. most hospitals probably have a medical library?

Resident work hours are only part of the problem here. The real issue is the workload and that has clearly not been addressed by any governing medical body. What should have been done alongside the reduction of hours for interns is to hire more interns so that the workload is balanced. There are hundreds of graduate MD's who do not match to an intern position each year, use these intellectual individuals, give them a job and make the workload more manageable for everyone.

I am a fellow (I have completed residency and am doing additional training in a subspecialty) and first of all, the 16 hour shift limit is only for interns - those in their first year of residency training. After your intern year, the limit increases to a 28 hour shift (with everyone limited to an 80 hour work week). When I go to work, my typical day is 12-16 hours and a call day, when I stay overnight, is 28 hours. I can sleep in my call room if my patients behave, but this is a luxury; many a night have I had where my patients were so sick I literally sat in their room and watched them all night. I have slept with my head against a ventilator or against a cardiac monitor because my patient was unstable and I couldn't leave. Every resident knows that you will break these regulations - both the 28 hour shift limit and/or the 80 hour work week limit. Anyone who says they never "go over hours" is lying. I have worked 110+ hours in a week and 34 hours in a row in the past. I have stayed late in order to care for a critically ill patient; I feel that stabilizing a patient is critical to my training, and I also know that patient better than someone just getting to work. As a physician in training, I want the experience of running an emergency situation while I still have the benefit of having my attending immediately available for backup if I reach the limit of my knowledge. This is not the kind of thing that you can learn in a text book. Running a "code" (a patient who is very acutely, critically ill or in cardiac arrest) effectively takes experience. The first few you run, you feel as if your own heart will stop! As the lead physician, you set the tone for the team caring for the patient; if you are frantic or panicking then your team will be, too. If you are calm, you can lead more effectively, have a smoother experience, and can more effectively care for the patient and figure out their problem. Not only this, there are some diseases or procedures that are so rare that even if you are "post-call", you stay to do/watch/discuss with the attending because you may never see this particular pathology or procedure again during training.

That being said, I completely agree that regulations need to be in place. I would even go so far as to say attending physicians should be regulated as well. However, with the 16 hour rule for interns, we now have interns (who will soon be supervising residents) who have less experience. When they become supervising residents, the new interns will be looking to them for guidance and if that experience isn't there, it will be the patients that suffer.

Now, not every time I have stayed late has been because of a critical patient. Many times, it's to finish work that needs to be completed before I go home. I spend over half of my day doing things not directly related to patient care: I make their follow up appointments, I find them physicians if they don't know who to go to when they're discharged from the hospital, I track down records from other facilities, I play social worker and case manager as well as doctor. I will also spend as much time as needed to answer questions about the patient's condition (I work in pediatrics, so I spend a lot of time talking to parents). Some require more time than others, but I believe that a parent should never wonder what the plan is, what's going on with their child, what is their child's diagnosis and what to expect, etc, so I will spend the time to talk. I realize that once I'm in the "real world" outside of training that I likely will not have this luxury of time.

Another thing previously mentioned that is definitely true is that the acuity of patients has increased greatly. This is not only because of forced shorter hospital stays. In my field (pediatric cardiology) many of my patients would have no chance of survival if they were born 10-15 years ago, but our technology has increased such that these babies are now surviving. However, these children are all chronically ill, in and out of the hospital, with very complex issues and require vigilant care not only on the part of the physician but also the parents. Many have complex surgeries and prolonged hospital stays, sometimes for weeks or months. They require very close observation in the hospital; a severe illness may have very subtle signs at first before becoming an all out emergency situation. Therefore, if you can spend the time checking on patients, with experience you can learn the subtle clues and hopefully notice small changes in the patient's condition and intervene to avert a crisis.

Why do I bring this up? If I'm spending my day tracking down patient X's medical records from another state (which can be a major hassle), trying to set up appointments, and other non-patient-care activities, I am not watching my patients. Therefore, it is easier for me to miss something. As we have more and more inexperienced nurses, they may not notice the subtle signs, either. As residents and fellows, we are hounded not to "go over hours" but sometimes this is impossible; many days I can complete my paperwork only after I sign out to the overnight physician. The bottom line is that if our hours will be this tightly regulated, then more personnel are needed to assist with the workload. However, because of budget cuts and decreased reimbursement, hospitals (they claim) do not have the budget to hire more residents or nurse practitioners to assist. So, for now, we are stuck with the workload we currently have.

Effective handoffs come with experience. As you gain more experience, you learn what is important to tell a new physician coming on to care for the patient, and you also learn what questions to ask and what information you need to have when you are the one covering. I, for one, always went to check out the patients with my intern...they would give the checkout but I was there for backup if needed. Another thing that's important is feedback - you will never learn from your mistakes if you don't know you made one. Rounds are an important part of training because that is when the whole team discusses a patient and the diagnosis and if you've made overnight decisions, you get feedback from the attending physician.

It is also helpful to have a person with whom to discuss a patient who is giving you trouble. Having residents of multiple levels of experience available is helpful; even if a night float person is "alone" in caring for a patient, there should be someone that they can contact, either an attending physician or a fellow resident, to "bounce ideas off of". I remember doing this many times.

In summary, I feel that regulation of "duty hours" (as we call them) is needed, but the people who have made the current rules are so out of touch with current training and patient care that they do not realize what kind of constraints the new regulations have put on physicians in training. If we had additional personnel to help with the workload (paperwork, insurance issues, etc) then we could spend more time caring for patients. You are more prone to make mistakes if you are more tired, true, but you can also make mistakes if you are overworked, hurried, caring for too many patients at once, and are not adequately supervised - all while being pressured to stay within your hour limits.

As someone who has gone through the process of residency, the key take home message here was that they did NOT hire more residents/MDs to cover the shorter hours and perhaps the residents were forced to squeeze work into fewer hours. For a long long time, nurses have been doing handoffs at least 2 times a day (3 shifts). MDs only do it once (2 shifts). It's not the handoffs (though certainly handoffs can always be improved). It's the lack of bodies(residents to do the work), the increased acuity of patients in the hospitals nowadays (insurance forcing people to get out ASAP and also when they come in they are sicker than previously), the extra unfriendly computer system (filled with silly bugs that slow us down).

I don't think an understanding has been reached. Shortening the amount of time to learn or cramming more learning into the time allocated may be missing the mark. Let's face it, medical mistakes kill more people than almost any other human activity. Perhaps lengthening the time to become a competent doctor is required. Medical knowledge has increased over time. The time to absorb that knowledge hasn't. What is the goal? Cranking out the required number of doctors from the "cookie press" or good medical outcomes?

I am a physician who trained under the older system in which there were no limits to the hours we worked. Sometimes I put in 120 hours in a week. Sometimes I ended up on call 3 or 4 days in a row. There was a problem with tiredness in those days, though, honestly, I do not remember this ever leading to harm for the patient (of course, maybe I was too tired to realize). In those days there was more of a team approach than I see in today's residents. Because everybody was on call more there generally were multiple levels of residents available in the same specialty simultaneously. As a first year resident, if I had trouble with something I could call on the residents above me to help. At the time this seemed to work quite well. Now there often is a single "night float" or a "nocturnist." Personally, I would rather be more tired than have no one else to talk to about what was happening, but I guess that those who do it now are well adapted to their roles. I have noticed the issue of "handoffs." Before the new system started, if I did a consult on a patient on the medical service I could always find the resident who was following the patient. That resident would typically know every detail. If I suggested some new orders he or she would discuss it with me and the old standard was that the resident would write the order because that was thought to be important in the training. Now I usually encounter the "night float" who rummages through a pack of note cards (or, more rarely, pages on his/her IPhone) and say "I really don't know this guy at all...I'm just the float. If you need any orders on him you'd better do it yourself because I won't get to it for 3 or 4 hours and I might forget." The night float generally looks well rested but he/she certainly seems harried with everybody else's patients (none of whom he/she knows or understands) under his care. I don't see a lot of mistakes under the new system either, but I see more potential for mistakes. Now that I am nearing retirement and will probably be consuming a lot of medical care myself soon, I sure wish that I could have the old system plus today's new technology for my care. But, I guess I'll have to live (or die) with whatever is in vogue when I need it.

These studies are fatally flawed by inaccurate data. Many teaching hospital institute policies to limit the hours residents can work in a week, including requiring daily logs of hours. However, residents routinely exceed any set limits, and falsify work logs to conform with policy. The overwork is a cultural fixture of modern medicine. Anyone who is a doctor knows this.

It's not the number of hours that they work it is the quality of people who go into medical career to begin with. The prestige has significantly decline in the last few decades and the top students go into business, finance and technology. So, we are left with leftovers.

RE: "interns reported that while they weren’t working as many hours, they were still expected to accomplish the same amount that previous classes had, so they had less time to complete their duties."

They should work 8 hour days, with the internship lasting more years than it used to. Not work fewer -hours-per-day than they used to, with the program lasting the same number of years and involving the same workload.

When I was in training (way back when) we worked up to 36 hours at a time. But we all took naps. There was a call room and I don't know anyone who didn't use it. It wasn't ideal but we sure learned a lot.

Adequate supervision by attending physicians is probably more critical to patient safety than sleep regulations. Too many programs put untrained interns in charge of patients while attending physicians are no where to be found.

So, interns are making more mistakes because they are expected to see the same number of patients in fewer hours? Welcome to the world of medicine. It will be the same when they get to be attendings and experience the trend to make doctors do more work in the same amount of time. Work compression is just a fact of life these days, for doctors (and all other workers for that matter) at all levels.

There are so many problems with this report that I do not know where to start.

1) The increase in handoffs does not necessarily translate into medical errors. Even if handoffs are associated with medical errors, is having residents work longer hours the solution? Why not train residents to have better handoffs?

2) The data are from self-reports from residents from a dozen national institutions. How were the institutions chosen? Were they chosen at random? How reliable were the self-reports? Were they further substantiated by actual records of medical errors? Self-reports are known to be prone to reporting bias and not being very accurate.

3) Why not consider some of the alternatives even if the self-reported data can be substantiated? Could the results of errors or depression be approximately the same because the hours have not been cut enough to make a difference? Could the residents still be too tired even after working 16 hours straight?

The bottom line is this: Pilots have work-hour restriction. Sleep deprivation is comparable to torture in the military sense and also comparable to being under alcoholic influence. This article does nothing but perpetuate the claims of attending doctors who hated the system when they were in it but want others to suffer through it because they had to go through it themselves. Show me hard and fast data, randomized data from repeatable studies that do not depend on unreliable self-report data before I will believe in these claims.

Hopefully, these flawed studies do not distract from the need for continued hour reductions. The teaching hospitals need to step up or be forced to step up and hire additional personnel to help prevent handoff errors. The elitist attitude held by many physicians must be struck down now and at the very least we should implement hour restrictions similar to those of pilots. This is common sense and if we as physicians or hospital administrators cannot implement these restrictions the power should be taken out of our hands.

Even before, the error rate was 19.9 percent. One in five. It's far better to live a healthy life, eat better and exercise (strength and aerobic). That will lead to far fewer medical problems that require a hospital visit. Of course, there are genetic conditions and accidents. But that's not why a lot of people are in the hospital these days. They are there because of avoidable conditions related to poor diet and inactivity. Keep yourself healthy so that you don't need to make frequent hospital visits, especially at younger ages.

Wow, this a real "Duh" moment. Didn't anyone think that the basic idea was to cut down on the workload? Did anyone say "Hey, you know what? If we cut the hours but still demand they do the same amount of work, absolutely nothing has been accomplished?"

This is like cutting back on gas but still driving the same amount of miles in less time.

Unfortunatley what is missing in the analysis is the critical idea that residents' "work" is emeshed with their training. The fewer hours of "work" the fewer hours there are of training and fewer opportunities there are for mentorship and education. Mistakes are increasing also perhaps because training is being compromised. There is defintinely room for improvement to the training and "work-life" of residents. However, we must be cautious that we preserve the ability of residents to have access to training opportunties, education, mentorship and experience so that patients can recieve excellent care and we create skilled doctors. 10,000 hours to achieve mastery.

Seriously? napping during the job? That just tells me that they are being forced to work to many hours! They should work no more than 8 hour shifts 4 days a week and add a few extra months to the residency. 12- 16 hour shifts is too much for anyone! Make the hospital hire extra employees and give everyone reduced shifts. I bet than you will see fewer mistakes. Instead of giving them 10 minutes with a patient they should spend longer than that to go over the chart and answer any questions/explain any treatment risks to the patient. If you increase the time they spend with each individual patient, decreased the number of hours they work, you will decrease their stress levels and allow them to get better sleep. If a person is rushing around for an entire 12 hour shift that is incredibly stressful, distracting, and probably doesn't allow them to concentrate on their patients. Honestly animals get better medical treatment in this country than people do! Sad when my vet spends 3 hours with my sick horse, but the hospital doctor spends 15 minutes with me.

When it comes down to it, Rediency training is an apprenticeship and experience is everything. You learn so much taking care of a patient from admission to discharge. What they will have to do with shourter working hours is increase the trainging time to make up for it. Residency is no fun but your goal is to get out of that training being the best physician you can be.

Too many people think read a book know it when a science and an art are mixed it takes mentor-ship and apprentice ship to learn when its an art and when it s pure science where exact input gives an exact result while as an art the action taken varies by the complications of the non uniform type of human with the variable of being different but similar to all others and what makes the difference between that is the why that it is an art as well as applied science.

We have become to obsessed with needing to make a profit in everything we do. There are to many unnecessary hands in the pot taking a cut from the medical dollar and limiting the available care. You are never going to provide quality care on a unreasonable limited budget. It takes what it takes to provide a certain level of care. As a society we need to decide what level of care we want. The cost needs to be spread to everyone because everyone benefits from the medical system. The only concern the medical community should be concern about is treating the patient. The patient should not be penalized because of their DNA, the poor practices by business to turn a profit at someone else's expense, bad judgement by society, or deceptive practices. We need knowledgeable and compassionate people who want to help others, not those who see people as a revenue source to fill their pockets. We do not need stockholders who are only concern about the return on their money in the system. Medicine should not be view as a profit making machine but rather as a service we provide to ourselves. Those who work in medicine should be compensated well according to the effort needed to attain the skills necessary for what they do. No business should make a profit on someone's pain, misery, or suffering.

As a RN since 1975 there have been huge changes in the hospitals adding to the errors. At one time a drug had one name now the same drug has many names adding to confusion and mistakes for healthcare workers and patients. Patients who had major surgeries stayed in the hospital and now they are tossed out after only a few days at most; making the patients in the hospitals extremely sick.

Staff levels have been reduced and older workers who were at the top of the pay scale are eliminated as Wall Street has taken over the health care industries FOR PROFIT. Benefits have been reduced or eliminated and in-sourcing of many jobs expecially nursing and out-sourcing of other jobs especially medical transcriptions have been taking place to replace USA labor with cheap foreign labor.

We are the only industrialized country that allows our health care system to run for profit leaving many uninsured for getting inferior care. If you are not very rich you can't affort to be sick in the USA. Many of the mistakes are due to rusing due to short staffing and extremely ill patients. Anyone who works eight to ten hours is exhausted; nurses and doctors.

The author fails to mention the effect of an explosion in administrative overhead in the health care field. More and more of our health care dollar is going to administrative overhead, taking money away from paying the doctors, nurses, and technicians who actually do the work taking care of patients. How could this affect errors? Simple. As the authority given to nameless, often poorly educated, and overpaid administrators rapidly increases, the smarter and more intelligent students are less likely to choose medicine as a career. Thus, the medical profession is dumbed-down as students realize how appealing administrative jobs are, with better pay, less responsibility, and shorter work weeks. The effect of an out-of-control, burgeoning bureaucracy was not taken into account.